Title: An act relating to primary medical eye care.

Brief Description: Establishing requirements for primary medical eye care.

Sponsors: Senators Keiser, Franklin, Kastama, Fairley, Marr, Delvin, Kohl-Welles, Brandland, Schoesler and Rasmussen.

Brief History:

Committee Activity: Health & Long-Term Care: 1/30/08, 2/07/08 [DPS, w/oRec].

SENATE COMMITTEE ON HEALTH & LONG-TERM CARE

Majority Report: That Substitute Senate Bill No. 6644 be substituted therefor, and the substitute bill do pass.Signed by Senators Keiser, Chair; Franklin, Vice Chair; Pflug, Ranking Minority Member; Fairley, Kastama, Kohl-Welles and Marr.

Minority Report: That it be referred without recommendation.Signed by Senator Carrell.

Staff: Mich'l Needham (786-7442)

Background: Many insurance carriers offer health plans that require medical care to be coordinated by a primary care physician, including referrals for specialty services. Some patients have encountered concerns with referrals for specialty eye care services and the associated insurance payment and patient cost-sharing, when such referrals have been made by eye care professionals rather than primary care providers.

Summary of Bill (Recommended Substitute): A definition of "primary medical eye care" and "primary medical eye care provider" are created in Title 48 (insurance statutes) to include all health care services within the optometry scope of practice, when provided by optometrists, osteopathic providers, and physicians. Primary medical eye care providers must be willing to serve as the medical home for primary medical eye care.

Beginning January 1, 2009, all insurance carriers offering health plans with primary medical eye care must provide enrollees a complete list of all contracted primary medical eye care providers, including those available through subcontracts. All contracted providers must be available to all enrollees, subject to service area requirements of the plan. Insurance carriers must allow enrollees to chose any contracted provider and allow enrollees to access eye care providers on the same terms as the primary care physician. Referrals for specialty eye care made by any contracted or subcontracted eye care provider must be deemed equivalent to a referral by a primary care physician for all purposes, including enrollee cost-sharing.

EFFECT OF CHANGES MADE BY HEALTH & LONG-TERM CARE COMMITTEE (Recommended Substitute): A definition for primary medical eye care provider is inserted. The change is required for contracts issued or renewed after January 1, 2009. Enrollees may choose providers within any service area requirements of the plan. Referring providers may be required to inform the patient's primary medical provider when a referral is made. Providers will be paid for covered services included in the plan. Language regarding non-discrimination of any health care providers because of the type of license held by the provider is removed.

Appropriation: None.

Fiscal Note: Available.

Committee/Commission/Task Force Created: No.

Effective Date: Ninety days after adjournment of session in which bill is passed.

Staff Summary of Public Testimony on Original Bill: PRO: Vision care is generally included in the medical coverage and many insurance contracts require patients to get referrals for specialty eye care from their medical primary care provider, adding out-of-pocket expense and delaying care. It will be more efficient for consumers to access their eye care provider of choice and receive a referral from that provider if necessary. Any delay in getting through a gatekeeper may damage one's vision.

CON: This bill runs counter to the model for the primary care medical home coordinating all the care for a patient. We disagree that this is a cost-saver and believe it may inappropriately steer people to more expensive care. Communication is the key to ensuring the referrals happen in a timely way to avoid any health risks for patients.

OTHER: We are not clear what the real problem is, nor are we clear if this is an attempt to move the 'every category of provider' requirement to an 'any willing provider' requirement. Some insurance plans are designed with a gatekeeper, primary care manager, and consumers have a choice of plans or products that don't have those requirements if they don't like using that model. This bill doesn't allow those models of care to continue to work as efficiently.

Persons Testifying: PRO: Brad Tower, Dr. Ken White, Optometric Physicians of Washington.

CON: Carl Nelson, Susie Tracy, Washington State Medical Association, Washington Academy of Eye Physicians and Surgeons; Dr. Aaron Weingeist, Washington Academy of Eye Physicians and Surgeons.

OTHER: Nancee Wildermuth, Regence Blue Shield, PacifiCare, Aetna.